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,AN JOAQUIN LOCAL HEALTH DISTR T '601 E, HAZELTON AVE., STOCKTO'-4 � ' Teicphonr; (2091 466-6787 .•' r. J, F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cornplete in Triplicate) Applicalron is hereby n.it d•r to:he San,rr.;Quin i"C'11 Hq:r[;h D:r7•c!Ice - . 1 made in;om !o nc q t^No.y59 in,sew prr}rt.��.ons`rar-r a•vf�nr ,s!aif 0—work-rein described. T!ric application!s p a e wrh Sar JOa uir.'cunN Ordu.an r aye,or No. 1617<^..or well purr•n aid the 8u'rs er - L6:aF Health❑istrict. d R-`Pula lions of the San Joaquin �f Q w r t r Jo!: Address 1..7.f'f J�i ! . - Cr��✓J•G � .__U.✓.�..�.L'. �'�_.._T �,-._J�'i.-- -. /"T.% z - .l� 'w Size - PNS — E ��77� _ owner's Name rfLcfLl•:i_. r?1 1 %�r>!. "_.. ...-.._.._.".. hen . N- Ar.dr s5 P e Contra�!or's Name rl TYPE --- - LSt Lr.en>n N• --� /, .) JJ 3 C1. a_S! vPE OF LVFLLrPUM?: Phone NE:V WU,L WELL PEF'rAL•F.n1F•dl•.. _- GESTRUCTZ' '. PUMP 1.'NSTIU.LATION F SYSTEM nEcAlff _ .. h DISTANCE TO NEAREST: SEPTIC ANK 'FUER LINES OTHER - .. ;SPOSC FID._. - R PROP t _ E --- •------�.__.._ FOUNDA 10 AL H!CLII, URF VJEL[ 0T)IF,R JF L -� SL'htP ti. INTENDED USE TYPE OF WELL PROBLEM ARF 9 . . - �Y CONSTRUCTION ION SP_F.CIFICATIONS_ ndustrial _—OpenBottom Mwiteca ia I Ewt•o, Dia. ia.sl Well-Casing omestic%Private ,.' Gravel Pack —' -------- TYnr'-Of CasiaU Public = Other . D^pth of Grout Spal Specifications Type 0 GrouiIrri Irrigation =__AoAroa,Depth �. Eastern Sur+ace Seal!rtstaiied Repair Work Done _ van e'PumpH,P._�� ,- St-Its tivo:k Done 7 Weft Destruction r-. Well Diameter _�p _-" Sealing Materia!Itop 50': -__ r cl ✓ Deplh._��SF..=..__,..- Fillelr Material Below 50'f TVpL OF SEPTIC WORK: NEW INSTALLATION REPAIR:ADDIT!OY'... DESTRUCTIt)N,.~IND se u•_ ' p system p_rmuted if public sewer is . Installation will serve' Residence-- Comn!ercial_ Oavailable within 20D feet.) ther_��_ i -''�• Number of living units: _— Number of bedrooms W_ -.—__. --.------ PAYMENT Character of sail to a depth of 3 feat:_ .Water tab) !'" 1 !4 N f SEPTIC TANK i Type,Mfg -------" -_._ =- ---- Capacity_____ . ------_..._.--..__._-. _ Na. Comp'4'I`LL:;J ;i -�1—rr�" PKG.TREATMENT PLT.i Method rt iR�bsj 0 II ryT Distance to nearesh. Wel; Foun9alion__ _ _ Property tin r.r n r r LEACHING LINE � i rr'r—',�I T�C'��,' No.& Length lines _ To!.Meng[h!si eltrlf?Cj�ll�',��;lr"iLi:",L�f'�•I�.,. !-S FILTER BED , Distance 10 nearest: Well_. Foundation—_ Property Line SEEPAGE PITS ED Depth _Size Number SUMPS 4r Distance to nearest: Well_ Foundation Prr,perty Line — DISPOSAL PONDS i7 I hereby certify that 1 have prepared this application and that the work will be done in accordance w°th Sari Joacitin county ordinances,state laws,and rues and regulations of the San Joaquin Local Health District. Home owner or Licensed agent's signature[ettifies the following: "I ceaify that in the performance of the work for which this permit is issued.I shall not employ any person in such manner as to become subject to wc-kman's compensation taws of California."Cortractors hiring or sub-contracting signature certifies the following:-'t certify that in the performance of the work for which this permit is issued•i shall employ porsons subject to workman's compensa- lion laws of California." - -- J The app&tant'must call foi-A required inspections.Complete drawing on reverse side. - Signed it Titet � -/rip Date- . EPAR 1eNTUS _NLY r Application Accepted by - . -Date_ �-1 - Pe J�Area Pito b Grout Inspection Date_ Final inspection by �!_ Additionat Comments: D Stk 466-6781 0 Lodi 369.3621 D Manters�823.7104 —C:Tracy 835-63A5 -- [ Applicant-Return all ccp;ns to: Environmental Health Permit/Services 1601 E. Hazollon Ave.. P_0. Box x'009, Stk,.CA 951.01 C]1 I f IFEE AMOUNT DUE AMOUNT AEh11T7E6. R£CEI•JED fiY DATE PERMR NO. • EM%3-I4 IREY. - EM:a.za - // f S co . I . I E I r E